Pressure Ulcer Myth-Busters - · PDF filePressure Ulcer Myth-Busters

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Transcript of Pressure Ulcer Myth-Busters - · PDF filePressure Ulcer Myth-Busters


    Cecelia L. Crawford, RN, MSN

    SCAL Regional Nursing Research Program


  • A Review of the Research Evidence

  • Narrative or Literature Review: Critical research summary on a topic of interest, often to put a research problem into context. 23

    Integrative Review: A systematic review using a detailed search strategy to find relevant evidence to answer a clinical question. Does not use summary statistics. 23

    Systematic Review: Comprehensive search strategies and rigorous research appraisal methods surrounding a clinical issue. Used to summarize, appraise, and communicate contradictory results or unmanageable amounts of research. 23

  • What is the quality of the evidence concerning Pressure Ulcer (PU) prediction and prevention in a variety of hospital settings and patient populations?

  • Search Terms: Braden Scale, operating room, pressure ulcer prevention, critical care, intensive careLimits: 1992-2006; 2002-2007Databases: Cochrane, CINAHL, Ovid, Medline, Pub MedWeb-Based: AORN website, Yahoo, Google

  • 2006 review for PU prediction & prevention83 articles/abstracts; 18 selected as relevant

    Variety of topics, settings, patient populationsCritical Care, Pediatrics, Long Term Care, Rehabilitation, Nursing HomesOperative patient experience evaluated

    2008 review updateCritical care environment examined in detailTwo WOCN interviewed for expert opinions282 articles; 14 reviewed, 8 selected as relevant

    4 articles from original review eliminated22 total relevant articles

  • Strength of individual research articles ranged from Insufficient to Good

    Quality of most PU research studies was often Insufficient due to deficiencies in research methods

    Final Grade for Body of Research Evidence: Fair

  • Research and other types of evidence allow healthcare providers to base their practice on science, rather than ritual, tradition, and myth

  • A collectively held belief that has no basis in fact ( body of traditional beliefs & notions accumulated about a particular subject ( unproved or false collective belief used to justify a social institution (

  • Drink 8 glasses of water per day 24Depends on individual & activity levelCan cause hyponatremia & heart failure

    We only use 10% of our brains 24Detailed studies havent found the missing 90%

    Reading in a dim light ruins eyesight 24Unlikely to cause permanent eye changes

    The higher the SPF sunscreen, the better 25SPF 15 blocks 93.3 % UV raysSPF 30 blocks 96.7% UV raysSPF 60 blocks 98.3 % UV raysSunscreen tips:

    Use frequently, with added blocking compounds

  • Examine 6 myths related to hospital acquired pressure ulcers

    Confirmed - truePlausible - maybeBusted - false

  • Risk assessment scales, such as the Braden Scale:

    decrease the incidence of pressure ulcersaccurately predict which patients are at risk of developing pressure ulcers

  • No evidence that the use of a RAS decreases PU incidence 17

  • Nurses are able to:Identify no risk & high risk patients 15

    Nurses have difficulty in:Identifying mild risk & moderate riskpatients 15

    One study showed the greatest number of PU occurred in the mild risk category 15

    Shortened versions of RAS do not ensure its correct use 15

  • RAS are useful tools for improvingThe effectiveness of providing pressure-reducing surfaces 17

    Preventive interventions 17

    Braden Scale offers the best balance between sensitivity, specificity, and risk estimate 17

    Experienced nurses are more likely to: 12Consistently assesses the skinIdentify PU stagesUse Braden scale correctly

  • Proper education and training will change a healthcare providers behavior

  • The presence of knowledge does not guarantee changes in traditional behavior 10

    Behaviors related to PU prevention can be erratic19

  • Intensive staff PU education can initially reduce PU incidence 8

    Gains are often lost over time 8

    Nurses will alter practice if change is not: 11

    Difficult or burdensomeTime consumingAdding to the workload

    Nurses may not be interested in changing their routines! 10

  • Regular & ongoing educational programs7,8Reframe PU Programs from a leadership & management viewpoint 8

    Create positive PU experiences 7,19Role modeling by respected colleagues 10Staff input regarding attitudes & beliefs surrounding PU assessment & prevention 19

    Provide staff with weapons for PU prevention

    Resources, checklists, guidelines, RAS 7,19

  • Turning regimes (i.e. turning a patient every 2 hours) are a key strategy to pressure ulcer prevention

  • There is insufficient evidence to recommend specific turning regimes 4,5,21

  • Anecdotally linked to Florence Nightingale: took her 2 hours to reposition every injured soldier on her ward (Crimean War,1853-1856) 7Attributed to a 1961 research study by Koziak which examined a 2 hour turning schedule 7More frequent repositioning on a pressure reducing mattress does not necessarily lead to fewer PU 5

  • Individualize care for at-risk patients 14Combine nursing judgment with PU tools and interventions 14Utilize the Braden Scale subscales to target specific PU prevention interventions 3,5,17,20,21

    Nutrition, Fiction & Shear, Moisture, Mobility, Activity, Sensory Perception

    Apply intensive PU prevention measures for patients for whom turning protocols are not effective 5Optimize patients nutritional status 4,18

  • Patients in critical care areas are more prone to developing PU

  • No single valid or discriminatory risk factor can be identified for PU development in the critically ill population 20

    Research data specific to the ICU is difficult to find 20

  • Use daily Braden scores from ICU admission to discharge 20

    One study reported 55% of patients with PU developed them within 2 weeks of admission 20

    Target specific ICU-related Braden subscales 20,22


  • Sedative effects on patient mobility may have an impact on PU development 20

    Patients most at PU risk were on sedatives, either alone or in combination with other vasopressor drugs

    Most critically ill patients are not routinely repositioned 21

  • Rotational beds do not reduce PU 4

    Higher-specification foam mattress preferred 21

    Cushioned surface facemasks may prevent facial PU 21

    Bowel Management Programs (i.e. Zassi, Flexi-Seal), may reduce moisture & decrease PU 22

    Paired with aggressive PU prevention program 22

    ICU Specific Equipment*

    *No studies documenting a superior device in PU prevention in critically ill patients 21

  • ALL surgical patients are at high risk of developing PU

  • ALL surgical patients should be considered at risk of PU development because of uncontrollable factors: 6,16

    Age Ethnicity Gender Body size OR time Hemodynamic


    Vasoactive Medications Comorbid conditions Nutritional status Pre-operative

    hypotension ASA scores Albumin levels

  • RAS can identify surgical patients at risk for PU development 16

    Pre-operative Braden Scale scores may be a predictor of PU formation 2

    Nutrition & mobility subscales may be predictive for OR acquired PU 18

  • Monitor the Controllable Factors


    Pooled Prep SolutionsShearing & FrictionSurgical PositionOR Surface

    Warming Blankets 2,6OR patients placed on warming blankets are at higher risk for PU

  • PU prevention is a staff nurse responsibility

  • PU prevention needs a multidisciplinary team effort to achieve the best outcome 4,19

    NursingPhysiciansOT/PTNutritional Services

    Nursing leadership and nursing management play a key role in supporting evidence-based PU initiatives 10

    Example: Management rounding of daily Braden Scores 20

  • Sustained commitment by leaders is necessary to make a change in philosophy stick and become embedded 11

    Organizations tend to underestimate the time needed to adopt the use of evidence to change nursing practice 11

    Complex healthcare environmentsLarge groups of nurses

  • Question long-standing routines & protocolsWhat are they based on ritual, tradition, myth?

    Learn computer skills to find the best evidenceData base searchesOrganizational websitesWeb-based search engines

    Change nursing practice in a systematic fashion, based on the best research evidence

    Not just one journal article that you like

  • For us who nurse, our nursing is a thing which, unless we are

    making progress every year, every month, every week, take my word for it, we are going back.

  • Cecelia L. Crawford, RN, MSNProject Manager IIIEvidence-Based Nursing PracticeKaiser PermanenteSCAL Regional Nursing Research

    [email protected]

  • 1. Agency for Health Care Policy & Research (1992). National Library of Medicine.

    2. Grous, C. A., Reilly, N. J., & Gift, A. G. (1997). Skin integrity in patients undergoing prolonged operations. Journal of